New Patient Intake FormDo you have a preferred dentist at our office? If so, who would you like to be seen by?:Are you interested in learning more about Invisalign? Yes No Unsure How did you hear about us or who should we thank for sending you to us?(Required)Patient Name: First Last Date of Birth: MM slash DD slash YYYY If Minor, Parent Name: First Last Mailing Address:(Required) Street Address Address Line 2 City ORAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (H):Phone (C):Email: Type:New General DentalNew EmergencyPain Scale:First Noticed:Area: UR LR UR LL Sensitive To: Pressure Hot Cold Biting ALL Previous Dentist:Last Cleaning:Have you ever been diagnosed with periodontal disease?Do you take a pre-med?Insurance Information:PLEASE NOTE: We do not accept OHP and are only a preferred/in-network provider for Regence of Oregon. While we can bill and collect from most insurances, your plan will dictate how they pay us. If you have a concern, you may contact your insurance to inquire if you can use your insurance at our office. Thank you!Insurance:YesNoIns Company:Subscriber:Who holds the insurance?Subscriber DOB: MM slash DD slash YYYY Group #:ID #:Ins Phone #:Employer:Additional comments or concerns you'd like us to know about:Additional Family Members:Patient Name: First Last Date of Birth: MM slash DD slash YYYY Relationship To Subscriber:Last Visit (exam & cleaning): MM slash DD slash YYYY Other Concerns:Patient Name: First Last Date of Birth: MM slash DD slash YYYY Relationship To Subscriber:Last Visit (exam & cleaning): MM slash DD slash YYYY Other Concerns:Patient Name: First Last Date of Birth: MM slash DD slash YYYY Relationship To Subscriber:Last Visit (exam & cleaning): MM slash DD slash YYYY Other Concerns:Patient Name: First Last Date of Birth: MM slash DD slash YYYY Relationship To Subscriber:Last Visit (exam & cleaning): MM slash DD slash YYYY Other Concerns:Patient Name: First Last Date of Birth: MM slash DD slash YYYY Relationship To Subscriber:Last Visit (exam & cleaning): MM slash DD slash YYYY Other Concerns:
